most challenges. the answer in many locations is organized women's groups and to make sure they have the expectation that their kids will be vaccinated, but they will get a bed net. in a lot of locations, there activism has been key to making sure that nothing is lost between the money being given and the services being delivered. in the case of vaccination, and people claim they are doing and when they are not, it is easy to go into surveillance. measles very quickly shows up people who claim to have higher rates but did not. >> thank you, mr. chairman. i was thinking as you were reviewing a lot of these issues that the impact to have both had on the world on a whole host of issues that relate to global

help, in one sense it is incalculable, but in another sense, very much measurable. mr. president, in your annual report, two numbers jumped out at me, reducing malnutrition among more than 42 million children, and providing access to safe drinking water -- to save drinking water in asia are among your many results. there are so many ways to document the problems, so many ways to specify the nature and the gravity of the threat to human life, but the american people more and more look to us and to non-governmental entities for results. i wanted to focus on the two areas. one is on maternal and child deaths and one is on food security.

let me just cite two numbers from the staff memo. sub-saharan africa and asia accounted for 92% of all under five deaths in 2000. the sec and related number, the same area accounted for 90 q -- 94% of all maternal deaths in 2005. i think the question i have is to fold. -- two fold. this year the president's budget and provides a $9.6 billion for global health activities. if we had another billion or two to spend, and you could only spend it hypothetically on maternal and child health, the question i would ask is, how would you spend that extra money

if we can only spend it in these areas? secondly, just a list of what works. sometimes i think we had these discussions and debates and we do not itemize or list what we know works and what we know we can invest in and get results. >> if i had another billion dollars to spend, you take ethiopia, for example. when we started in ethiopia, there were only 700 clinics in the country. that is before the united states program got under way. we help them develop a plan to go to 3500 clinics. i would go in and try to make sure that every pregnant mother could be checked, could be part of some community health worker

network and eventually get to a clinic before a baby is born. i would make sure we had adequate nutrition. i would make sure that in the high prevalence areas we tested for hiv status and gave the mother to child transmission drugs. i would then find those things that reduce infant mortality. you talk about all these kids that dye being in africa. the mortality rate is very grievous for babies born with hiv aids. even though we say a lot of them receive even though we save that a lot of them, it is horrible. 80% of the people that die from waterborne diseases are under 5. they are almost all in poor countries. that is what i would do. i would spend money on that. >> i mentioned at the drop in

childhood deaths to 9 million. we cannot think of the remaining workers as the death between 30 days of age and five years, where it is really going to be vaccines that carry the weight. we have a new vaccine for part of the pneumonia burden. hopefully we will have a few more, and we will have a malaria vaccine. if you could cover those disease conditions, you could cut the 30 day to a five-year piece by well over half. that would still leave a gigantic number in those first 30 days. that is where all these words about integrated approaches come in. if you get the mother, starting at prenatal, making sure she has the right vitamins, make sure she has the clean birth kit, some antibiotics, make sure she has been given the right advice about keeping the baby warm,

breast feeding, vaccination. that integrated approach can save over half of the children that died during that first 30 days. that is a big new focus, not only g with thathi plan, but work we are doing. exactly how you go about that is not well understood. we need to put more into research. the first 30 days peace, there is a lot we know, but there is more that we need to know, because creating the demand by the mothers within their culture that they will want these services, in many places to go, you tell them to take the shot to the clinic. that answer is, that is where you go to die, so why would i take my child bear? there are some new ideas on this that would be tailored to each

local area. >> bill just said something -- i think it is very important to understand that partly because of the way programs get funded in the countries providing aid, and partly because of the absence of systems in poor countries, it is hard for you to believe just sitting here, but the most important thing maybe about this ghi proposal is providing a coherent health system in a one-stop place in developing countries. it is crazy that they do not have enough money to do anything. you have this program dealing with aids in this one dealing with malaria. there are literally places where you have to walt to get health care, you may have to walk three or four or five

places to get everything your family needs. this is what the global health initiative will correct, and will give the rest of us marching orders in a framework so we can all be more effective, and make the money you have appropriated go further. i think it is really important that everybody understands. it is hard to imagine that this exists, but it does. it may be the most important reason for you to reasonthe ghi. >> is that the consequences of what we are doing are not doing, or what the individual countries are doing or not doing? >> probably a little bit of both. i think it is a lot of people in developed countries providing aid with really good intentions.

you cannot start a program immunizing against other tropical diseases -- i could go on. what we said earlier is that the united states and other donors need to be in the business of making this a user-friendly system, and also helping to build the capacity of the countries in which we were, and hopefully one day they will not need us anymore or anybody else. what happens is, if you deal with these things problem after problem, you have unintended consequences if you put the problem solvers into an environment where there is no system like we take for granted for health care. >> what you are saying i suppose is that when these things are done, they should focus at the

outset on system and process as much as they do on delivery. >> absolutely. the problem of all the major debates in rich countries about health care policy, education policy, and all this. they are about how do you change the system you have. what is the right and wrong way to do it? in poor countries, they are about capacity. they have no systems, so there is no predictability in the connection between what you do and the consequent you get. i think this is noble work. you can see the u.s. government doing more of it. bill gates foundation and i have been involved. i am just as guilty as the next person. we were so proud when we cut the price of aids drugs. then we did something on malaria. presume we realize that the

impact of all this is being drastically truncated in places where there were no health care systems, where people would also show up and get maternal and child health or whatever. >> i want to add my thanks to everyone else on the panel to both of you for being here today and for all the work you have done. thank you both very much. for the last year, along with senator snowe, i have served on the smart local help commission of csis. we are getting ready to produce a report that will come out next week. reinforces so much of what other you have said today. many of your friends and colleagues have served on that commission with me. i would like to ask unanimous consent if we can submit in the report and advanced copy of the csis report.

one of the things that is talked about in that report is exactly what you both said about building a system that can deliver results, and as we look at how to structure that kind of a system that i think is important, not just in terms of delivering results, but in producing a base that we can go back to people, whether it is funders our government or the american people and say this works, and we have the accountability and data to show that. can you talk a little bit more about that, about how we structure those systems that work accountable for people? >> in some ways, compared to all the money you spend, this is the

most accountable money, more than the money spent on medicare, the defense budget, even education. this money, you can say we spent this many dollars and saved this many lives. at levels where it is stunning that those resources were not there in the past. the piece that is not in the budget, the research pieces that are over in the other thing, those are little tougher. we cannot say how quickly we will get an aids vaccine. we know it is important work, but it is a long quest, probably more than a decade. when it comes to giving money to global funds or to the blinds for vaccines, there is a very direct measurement of how many

kids lives were saved with these new vaccines, or how many new people were able to go on treatment. i think -- i wish all of government had such a clear idea of if you spend money, you will absolutely get this result. of the rich world government budgets, it was less than half of% -- half of 1% that caused that to take place. >> i completely agree with that. if i could be the curmudgeon here, because i am a bleeding heart cheapskate, and we need more money for medicine, for reasons we have already outlined. i do think this is an appropriate time for you to reexamine the transaction cost, the compliance costs, and the

overhead costs, to see if you can squeeze any more money out of the money that congress appropriates and get it spent in the communities where you intended to in other countries or for buying medicine. one of the things in the report on the global health initiative that the administration has issued, and you will have that testimony later today, there was mention of cooperation with ngo's. one of the things we have not worked through is exactly what should the nature of the government's cooperation with ngo's be? i described my relationship with the bush administration, but i am in a different position. i cannot and do not want to get u.s. government money, although we have made our health initiative freestanding, in the

event is necessary some time. you need to think about how you do these things faster, cheaper, and better, and whether we really have the highest percentage of dollars being spent in the countries you intend them to go to as possible. in my opinion, there may be some things you can do to improve that. all these things are a score of will. you can keep score. you know what you got for the money you spent. that does not mean you should not keep trying to get more blood out of the turn up. we have desperate needs, and the more we build these systems, the more people will show up. five years from now, you do not want to have rights in countries because they can only give medicine to 45% of the people who need it to stay alive, and the other 55%, you did not see before you build the system, to touch them.

>> that leads me to raise another issue that has been sensitive and controversial, but it is important as we talk about how do we best invest the dollars. as we all know, family planning remains a controversial issue in this body and in the country. mr. gates, you mentioned in your written testimony that voluntary family planning is a proven and cost-effective way to save lives. according to the csis report, for every $100 million invested in family planning, 4000 maternal lives are saved, 70,000 infant deaths are prevented, and $820,000 -- 820,000 abortions are averted. how can we move this debate beyond this topic being controversial, to being another way to accomplish what we need to to deliver health care for people around the world?

>> mr. president, i understand you have a deadline. >> i can stay until 12:00. >> thank you, mr. president. >> i think the best way to change people's minds is to have them go to the countries and see what is being discussed when we talk about family planning in these countries. talk to the mothers who want access to the tools. the tools can improve a lot of women -- a lot of women use injections. that is and deal, so you have to go to a health worker. the new advances are subcutaneous. the person cannot get at the pharmacy and administer it themselves. the implants have been way too

expensive. there is a new generation of those coming out that are substantially less expensive. what voluntary family planning means is bringing down by choice the rate of population growth, and having more birth spacing. that is very dramatic in terms of improving maternal health. if you wait two years between children, it cut swore then have the chance that there will be a maternal complication -- cuts more than half the chance that there will be a maternal complication. in these very poor places, a high population growth builds then huge problems for the future. it's great to see the u.s. looking at these investments and

that that receives some what of an increase in the ghi budget. it is an important area that are foundation prioritizes as well. >> here is my recommendation. i do not know if it will work or not. ask your colleagues here, but i think the foreign relations committee should start with members and staff members going to see some of these places, because i think -- win a pro- life person hears the word family planning, they think abortion. if you could see these things in operation, the come across as clearly pro-family, and profoundly pro-life. these poor women, they are just

trying to manage their lives. if they space out the births, they can do a better job as mothers. they can still work and earn income for the family. it changes everything for them. i personally think that your best bet is for people, whether they are viscerally for or against this, to actually see it, see how it works in real people's lives. i think that would change things. i don't think he should give up on this. who would have thought that jesse helms would have supported the global debt relief initiative in 2000? who would have thought that by the time president bush timepepbar that we would have had everyone in the world on the bandwagon? is important to keep working at it. most people who talk about family planning have never seen

it in operation on the ground on site. >> thank you so much for being here. i appreciate the work that both of you continue to do for the benefit of all humanity. mr. president, i agree completely when you talk about vaccinations. they are cheap and they work. i appreciate what you said, they must be invited in and you must have measurable results. i agree with the integrated approach to care. i saw as an orthopedic surgeon how important that is, early detection, prevention, all of those things in an integrated approach and the one-stop shopping you talked about where people can go. what i hear from my colleague who has had a chance to visit these locations is that the

patients and the people want to go to the gates facility much more than the local, state or government run facility. apparently you have come up with a better way with transportation and sending a van to under 30 miles around. it is all these other ancillary things we can do to help improve the system. i look forward to having a chance to visit the facilities as well. if you could talk about how the aids foundation has set up criteria for when you decide to get involved, and holding people accountable for continuation of support. you want to make sure that the value is there for the dollars invested and the best results can be obtained. >> the gate foundation gives money to the global fund because we think is a great organization. i think we have given $650

million to them at this point. they work with the countries, they have quite low overhead in terms of how they do it. in terms of setting up clinics, there is a difference between high aids prevalent countries and low aids prevalent countries. a little bit of the mistake was taking them -- it really makes sense because of the adult health care delivery. botswana, south africa, as you move to countries like rwanda and ethiopia where the aids prevalence is more in the 2% range, there you do not want to create a separate structure. having the judgment to look at the aids prevalence, rural versus urban, there are decisions that get made. there is a lot of learning going

on. i would not characterize the field as it vertical levers and health system levers. is it about taking particular axe and circumstances and coming up with the right approach. country by country, i do see that being done. taking a few countries to be model countries, and having some funds that are un program that would help them drive those model programs. >> i think you hit on something. we gave a specific example of a general issue that i would urge you to explore with the administration officials when they come. nobody has an answer for this, at least i don't. i have already said here, i strongly support this ghi initiative. it is well conceived. it is what we ought to do. but when you ask us, what should

the government shouldx's relationship be with the ngo community? what should the american government's relationship be to that government? for example, i know you know that we do not give foreign assistance to other countries for direct budget support. that makes a lot of sense, when you first hear it, because we want to achieve certain specific examples -- objectives, and we do not want to find ineffective government. on the other hand, we are now coming up and saying we have to build health care systems in this country. i just want to urge you to keep pushing this and keep thinking through this period and user experience as a physician with the health care system. if the end of this is, if the

definition of success is they have their own health system and works as well as anybody could, given that amount of money, how or going to relate it to the government and how will the u.s. assistance program relate to the ngo program? if you read the ghi report, there is a good description of what they did in bangladesh. you need to really work through this, i think. >> if i could ask a couple of things before we wrap up. africa has your doctors, fewer trained medical personnel than any other region and apparently continues to lose many of those who are trained to either north america or europe. i wonder how we can help to

prevent that from happening, and to take the underserved regions and empower them to be able to build their indigenous come up permanent medical corpe. h>> there are plenty of gifted people there that want to stay and will stay be trained community health workers and provide facilities, including doctors. a lot of the doctors will stay at home and make less money than they could hear, as long as they do not have to fail as doctors. as long as they have a health care network that makes sense. secondly, i think we need to --

we have to recognize that the african university system declined over decades as the colonial era faded away to an astonishing degree. now you have all these american universities opening in the middle east. i am for it. i love it. you have all these universities because that is where the money is. i think it is good for us in the long run, good for america and the middle east. we maybe should think about finding the same sort of help and africa where our universities could be there in partnership with african universities and build their capacity, even as there is an architecture school from the university of north dakota their. i think he should really think about it.